NOVEL Project Proposal to Collaborate

Misplacement of temporary feeding tubes, such as nasogastric tubes (NGT), are estimated at 1-2% of all placements. This extrapolates to around 30,000 events annually with outcomes ranging from no harm to severe lung injury or death. This is a patient safety issue, and we ask you to join us in our effort to improve nursing practice in the NICU area by defining best practice for NGT placement verification.

In 2012, the American Society for Parenteral and Enteral Nutrition (ASPEN) sent letters to over 30 pediatric organizations to solicit support for the development of best practices related to NGT placement verification for infants and children.  Several organizations were asked to designate a member to act as a liaison to the workgroup being formed.  All organizations returned a letter supporting this project, and most agreed to designate a representative to become a member to what is now the NOVEL project (New Opportunities for Verification of Enteral tube Location).  The NOVEL project has members from ASPEN, AACN—American Association of Critical Care Nurse,

APGNN—Association of Pediatric Gastroenterology and Nutrition Nurses, SPN—Society of Pediatric Nurses, Child Health Patient Safety Organization, and a parent whose son died on Day of Life 10 from a misplaced NG tube.

We also have recently added a newly retired nurse executive and a neonatal NP/researcher

Our mission is two-fold:

  1. To define and disseminate best practice for NGT placement verification for infants and children
  2. To work with industry and inventors to develop technology that allows for real time verification of NGT tip placement.

In 2014-2015 we conducted a 1-day prevalence study to determine the number of NGTs used in patients within US hospitals.  We had 63 hospitals participate in the study and found 24% of neonates, infants, and children hospitalized in the US have an NGT, orogastric or post pyloric feeding tube.   Of these patients, 61% were in the NICU. Most of the centers in our study used auscultation and aspiration (33 and 38.5% respectively) to verify NG tube placement—both of which have been denounced by many organizations as inaccurate and in conflict with existing evidence.  The use of evidence-based method(s) such as pH measurement or radiograph was used only 15.8% and 10% respectively.

A research study was conducted in 2020 by Northington to follow-up on work done in 2015 to determine practice changes and progress regarding use of evidence-based methods to verify NGT placement.  Our results showed 42% of respondents use pH and 23% use a radiograph to verify NGT placement in this population.  However, many respondents indicated that their NICU staff often continue to use auscultation or aspiration.  Overwhelmingly, the reasons cited for not using a radiograph are concerns for radiation exposure which has a cumulative effect over time.  We also noted concerns from NICU staff that pH is probably inaccurate in this population.  While a large study done by Kemper  et al (2019), does refute this assertion, we do acknowledge that the majority of the study population were not ELBW neonates and a confirmatory radiograph to confirm placement was not performed.  Our goal is to replace inaccurate methods for NGT placement with evidence-based method(s).

For reasons stated above, the NOVEL project recommends convening a NICU work group to address these challenges and define best practice as it pertains to NG tube placement verification in the NICU population.  Additional research may be needed to answer specific practice questions and add to the body of evidence, and we are interested in having NICU partners for future study.  We will begin with every other month conference calls to clearly define these issues and to determine next steps.  The intent of this project is not to prove pH measurement is effective in the NICU, but we do want to evaluate if is the practice is or is not effective in ELBW infants.  We enter this endeavor with an open mind.

In an effort to get a better initial idea of where things stand in the NICU, would you please answer 2 survey questions in this link?   https://www.surveymonkey.com/r/M9YCH3C

Please see our body of work to date below:

  • Irving SY, Lyman B, Northington L, Kemper C, et al. Nasogastric tube placement and verification in children: a review of the current literature. Nutr Clin Pract, 2014; 29(3):267-276.
  • Lyman B, Kemper C, Northington L, Yaworski JA, et al. Use of temporary enteral access devices in hospitalized neonatal and pediatric patients in the United States. 2016:40(4); 574-580.
  • Lyman B, Yaworski JA, Duesing L, Moore C. Verifying NG feeding tube placement in pediatric patients. American Nurse Today, 2016; 11(1):1-2.
  • Northington L, Lyman B, Guenter P, Irving S, Duesing L. Current practices in home management of nasogastric tube placement in pediatric patients: a survey of parents and homecare providers. J Ped Nurs. 2017;33 (1):46-53.
  • Lyman B. Nasogastric tube placement in critically ill pediatric patients. Crit Care Nurse. 2017;37(6): 86-87.
  • Lyman B, Rempel G, Windsor K, Guenter P. Uses of nasogastric feeding tubes for children at home: a template for caregiver education. Nutr Clin Prac. 2017;32(6): 831-833.
  • Irving SY, Rempel G, Lyman B, Sevilla WM, Northington L, Guenter P, et al. Pediatric nasogastric tube placement and verification: best practice recommendations from the NOVEL project. Nutr Clin Prac. 2019; 33(6):921-927.
  • Kemper C, Haney B, Oschman A, Lee B, Lyman B, Parker L, Brandon D. Acidity of enteral feeding tube aspirate in neonates: do pH values meet the cutoff for predicting gastric placement? Adv Neonatal Nurs.2019;19(4):333-341.
  • Northington L, Kemper C, Rempel G, Pauley R, Lyman B, et al. Evaluation of methods used to verify nasogastric feeding tube placement in hospitalized infants and children – A follow-up study. J Ped Nurs. 2021; doi: 10.1011/j.pedn.2021.10.1018.

If you or someone you work with is interested in helping form a work group to address this issue, please contact Beth Lyman, MSN, RN, CNSC, FASPEN, FAAN at lymanb2954@gmail.com.

We Want to Hear From You

In an effort to get a better initial idea of where things stand in the NICU, would you please answer 2 survey questions?